|
DRESSING AMD 3X8 TELFA 7663"
|
Facility
|
OP
|
$62.00
|
|
| Hospital Charge Code |
2963151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.36 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Aetna Managed Medicare |
$17.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$40.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$31.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34.70
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$46.50
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$40.30
|
| Rate for Payer: Quartz Medicare Advantage |
$37.20
|
| Rate for Payer: The Alliance Commercial |
$248.00
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
DRESSING AMD 3X8 TELFA 7663"
|
Facility
|
IP
|
$62.00
|
|
| Hospital Charge Code |
2963151
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$30.38 |
| Max. Negotiated Rate |
$57.04 |
| Rate for Payer: Aetna Commercial |
$55.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$53.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$32.86
|
| Rate for Payer: Cash Price |
$18.60
|
| Rate for Payer: Cigna Commercial |
$57.04
|
| Rate for Payer: Health EOS Commercial |
$55.18
|
| Rate for Payer: HFN Commercial |
$57.04
|
| Rate for Payer: Multiplan Commercial |
$49.60
|
| Rate for Payer: NAPHCARE Commercial |
$37.20
|
| Rate for Payer: Preferred Network Access Commercial |
$57.04
|
| Rate for Payer: Quartz Beloit One Network |
$30.38
|
| Rate for Payer: Quartz Commercial |
$37.20
|
| Rate for Payer: WEA Trust Commercial |
$34.10
|
| Rate for Payer: WPS Commercial |
$45.92
|
|
|
DRESSING AQUACEL AG 2X45CM 422300
|
Facility
|
IP
|
$331.00
|
|
| Hospital Charge Code |
2963483
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$162.19 |
| Max. Negotiated Rate |
$304.52 |
| Rate for Payer: Aetna Commercial |
$297.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.43
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$304.52
|
| Rate for Payer: Health EOS Commercial |
$294.59
|
| Rate for Payer: HFN Commercial |
$304.52
|
| Rate for Payer: Multiplan Commercial |
$264.80
|
| Rate for Payer: NAPHCARE Commercial |
$198.60
|
| Rate for Payer: Preferred Network Access Commercial |
$304.52
|
| Rate for Payer: Quartz Beloit One Network |
$162.19
|
| Rate for Payer: Quartz Commercial |
$198.60
|
| Rate for Payer: WEA Trust Commercial |
$182.05
|
| Rate for Payer: WPS Commercial |
$245.17
|
|
|
DRESSING AQUACEL AG 2X45CM 422300
|
Facility
|
OP
|
$331.00
|
|
| Hospital Charge Code |
2963483
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.68 |
| Max. Negotiated Rate |
$1,324.00 |
| Rate for Payer: Aetna Commercial |
$297.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$284.66
|
| Rate for Payer: Aetna Managed Medicare |
$92.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$215.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$165.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$158.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$175.43
|
| Rate for Payer: Cash Price |
$99.30
|
| Rate for Payer: Cigna Commercial |
$304.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$185.23
|
| Rate for Payer: Health EOS Commercial |
$294.59
|
| Rate for Payer: HFN Commercial |
$304.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$248.25
|
| Rate for Payer: Multiplan Commercial |
$264.80
|
| Rate for Payer: NAPHCARE Commercial |
$198.60
|
| Rate for Payer: Preferred Network Access Commercial |
$304.52
|
| Rate for Payer: Quartz Beloit One Network |
$162.19
|
| Rate for Payer: Quartz Commercial |
$215.15
|
| Rate for Payer: Quartz Medicare Advantage |
$198.60
|
| Rate for Payer: The Alliance Commercial |
$1,324.00
|
| Rate for Payer: WEA Trust Commercial |
$182.05
|
| Rate for Payer: WPS Commercial |
$245.17
|
|
|
DRESSING AQUACEL AG ADVANTAGE 4X5 422299
|
Facility
|
IP
|
$188.00
|
|
| Hospital Charge Code |
5456957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$92.12 |
| Max. Negotiated Rate |
$172.96 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$112.80
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
DRESSING AQUACEL AG ADVANTAGE 4X5 422299
|
Facility
|
OP
|
$188.00
|
|
| Hospital Charge Code |
5456957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.64 |
| Max. Negotiated Rate |
$752.00 |
| Rate for Payer: Aetna Commercial |
$169.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$161.68
|
| Rate for Payer: Aetna Managed Medicare |
$52.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$122.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$94.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$90.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$99.64
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cigna Commercial |
$172.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$105.20
|
| Rate for Payer: Health EOS Commercial |
$167.32
|
| Rate for Payer: HFN Commercial |
$172.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$141.00
|
| Rate for Payer: Multiplan Commercial |
$150.40
|
| Rate for Payer: NAPHCARE Commercial |
$112.80
|
| Rate for Payer: Preferred Network Access Commercial |
$172.96
|
| Rate for Payer: Quartz Beloit One Network |
$92.12
|
| Rate for Payer: Quartz Commercial |
$122.20
|
| Rate for Payer: Quartz Medicare Advantage |
$112.80
|
| Rate for Payer: The Alliance Commercial |
$752.00
|
| Rate for Payer: WEA Trust Commercial |
$103.40
|
| Rate for Payer: WPS Commercial |
$139.25
|
|
|
DRESSING AQUACEL FOAM 4X4 ADHESIVE 420680
|
Facility
|
IP
|
$101.00
|
|
| Hospital Charge Code |
2963583
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$92.92 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$60.60
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
DRESSING AQUACEL FOAM 4X4 ADHESIVE 420680
|
Facility
|
OP
|
$101.00
|
|
| Hospital Charge Code |
2963583
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.28 |
| Max. Negotiated Rate |
$404.00 |
| Rate for Payer: Aetna Commercial |
$90.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$86.86
|
| Rate for Payer: Aetna Managed Medicare |
$28.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$65.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$50.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$48.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$53.53
|
| Rate for Payer: Cash Price |
$30.30
|
| Rate for Payer: Cigna Commercial |
$92.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$56.52
|
| Rate for Payer: Health EOS Commercial |
$89.89
|
| Rate for Payer: HFN Commercial |
$92.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.75
|
| Rate for Payer: Multiplan Commercial |
$80.80
|
| Rate for Payer: NAPHCARE Commercial |
$60.60
|
| Rate for Payer: Preferred Network Access Commercial |
$92.92
|
| Rate for Payer: Quartz Beloit One Network |
$49.49
|
| Rate for Payer: Quartz Commercial |
$65.65
|
| Rate for Payer: Quartz Medicare Advantage |
$60.60
|
| Rate for Payer: The Alliance Commercial |
$404.00
|
| Rate for Payer: WEA Trust Commercial |
$55.55
|
| Rate for Payer: WPS Commercial |
$74.81
|
|
|
DRESSING ARGLAES 3.25 X 14 MSC9314Z
|
Facility
|
OP
|
$652.00
|
|
| Hospital Charge Code |
2965289
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$182.56 |
| Max. Negotiated Rate |
$2,608.00 |
| Rate for Payer: Aetna Commercial |
$586.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$560.72
|
| Rate for Payer: Aetna Managed Medicare |
$182.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$423.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$326.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$312.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.56
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$599.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$364.86
|
| Rate for Payer: Health EOS Commercial |
$580.28
|
| Rate for Payer: HFN Commercial |
$599.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$489.00
|
| Rate for Payer: Multiplan Commercial |
$521.60
|
| Rate for Payer: NAPHCARE Commercial |
$391.20
|
| Rate for Payer: Preferred Network Access Commercial |
$599.84
|
| Rate for Payer: Quartz Beloit One Network |
$319.48
|
| Rate for Payer: Quartz Commercial |
$423.80
|
| Rate for Payer: Quartz Medicare Advantage |
$391.20
|
| Rate for Payer: The Alliance Commercial |
$2,608.00
|
| Rate for Payer: WEA Trust Commercial |
$358.60
|
| Rate for Payer: WPS Commercial |
$482.94
|
|
|
DRESSING ARGLAES 3.25 X 14 MSC9314Z
|
Facility
|
IP
|
$652.00
|
|
| Hospital Charge Code |
2965289
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$319.48 |
| Max. Negotiated Rate |
$599.84 |
| Rate for Payer: Aetna Commercial |
$586.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$560.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$345.56
|
| Rate for Payer: Cash Price |
$195.60
|
| Rate for Payer: Cigna Commercial |
$599.84
|
| Rate for Payer: Health EOS Commercial |
$580.28
|
| Rate for Payer: HFN Commercial |
$599.84
|
| Rate for Payer: Multiplan Commercial |
$521.60
|
| Rate for Payer: NAPHCARE Commercial |
$391.20
|
| Rate for Payer: Preferred Network Access Commercial |
$599.84
|
| Rate for Payer: Quartz Beloit One Network |
$319.48
|
| Rate for Payer: Quartz Commercial |
$391.20
|
| Rate for Payer: WEA Trust Commercial |
$358.60
|
| Rate for Payer: WPS Commercial |
$482.94
|
|
|
DRESSING ARGLAES 4 X 4 MSC9045Z**DEDE 11/19
|
Facility
|
OP
|
$574.00
|
|
| Hospital Charge Code |
3331523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$160.72 |
| Max. Negotiated Rate |
$2,296.00 |
| Rate for Payer: Aetna Commercial |
$516.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.64
|
| Rate for Payer: Aetna Managed Medicare |
$160.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$373.10
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$287.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$275.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.22
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$528.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$321.21
|
| Rate for Payer: Health EOS Commercial |
$510.86
|
| Rate for Payer: HFN Commercial |
$528.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$430.50
|
| Rate for Payer: Multiplan Commercial |
$459.20
|
| Rate for Payer: NAPHCARE Commercial |
$344.40
|
| Rate for Payer: Preferred Network Access Commercial |
$528.08
|
| Rate for Payer: Quartz Beloit One Network |
$281.26
|
| Rate for Payer: Quartz Commercial |
$373.10
|
| Rate for Payer: Quartz Medicare Advantage |
$344.40
|
| Rate for Payer: The Alliance Commercial |
$2,296.00
|
| Rate for Payer: WEA Trust Commercial |
$315.70
|
| Rate for Payer: WPS Commercial |
$425.16
|
|
|
DRESSING ARGLAES 4 X 4 MSC9045Z**DEDE 11/19
|
Facility
|
IP
|
$574.00
|
|
| Hospital Charge Code |
3331523
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$281.26 |
| Max. Negotiated Rate |
$528.08 |
| Rate for Payer: Aetna Commercial |
$516.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$493.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$304.22
|
| Rate for Payer: Cash Price |
$172.20
|
| Rate for Payer: Cigna Commercial |
$528.08
|
| Rate for Payer: Health EOS Commercial |
$510.86
|
| Rate for Payer: HFN Commercial |
$528.08
|
| Rate for Payer: Multiplan Commercial |
$459.20
|
| Rate for Payer: NAPHCARE Commercial |
$344.40
|
| Rate for Payer: Preferred Network Access Commercial |
$528.08
|
| Rate for Payer: Quartz Beloit One Network |
$281.26
|
| Rate for Payer: Quartz Commercial |
$344.40
|
| Rate for Payer: WEA Trust Commercial |
$315.70
|
| Rate for Payer: WPS Commercial |
$425.16
|
|
|
DRESSING BANDAGE ROLL GAUZE 3331 STERILE
|
Facility
|
IP
|
$76.00
|
|
| Hospital Charge Code |
2963145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.24 |
| Max. Negotiated Rate |
$69.92 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$45.60
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
DRESSING BANDAGE ROLL GAUZE 3331 STERILE
|
Facility
|
OP
|
$76.00
|
|
| Hospital Charge Code |
2963145
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$304.00 |
| Rate for Payer: Aetna Commercial |
$68.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$65.36
|
| Rate for Payer: Aetna Managed Medicare |
$21.28
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$49.40
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$38.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$36.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$40.28
|
| Rate for Payer: Cash Price |
$22.80
|
| Rate for Payer: Cigna Commercial |
$69.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$42.53
|
| Rate for Payer: Health EOS Commercial |
$67.64
|
| Rate for Payer: HFN Commercial |
$69.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$57.00
|
| Rate for Payer: Multiplan Commercial |
$60.80
|
| Rate for Payer: NAPHCARE Commercial |
$45.60
|
| Rate for Payer: Preferred Network Access Commercial |
$69.92
|
| Rate for Payer: Quartz Beloit One Network |
$37.24
|
| Rate for Payer: Quartz Commercial |
$49.40
|
| Rate for Payer: Quartz Medicare Advantage |
$45.60
|
| Rate for Payer: The Alliance Commercial |
$304.00
|
| Rate for Payer: WEA Trust Commercial |
$41.80
|
| Rate for Payer: WPS Commercial |
$56.29
|
|
|
DRESSING BARRIER FLEXTEND CTF 4X4 8800
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS A4385
|
| Hospital Charge Code |
4063434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$45.08 |
| Max. Negotiated Rate |
$84.64 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$55.20
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
DRESSING BARRIER FLEXTEND CTF 4X4 8800
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS A4385
|
| Hospital Charge Code |
4063434
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$368.00 |
| Rate for Payer: Aetna Commercial |
$82.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$79.12
|
| Rate for Payer: Aetna Managed Medicare |
$25.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$59.80
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$44.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$48.76
|
| Rate for Payer: Cash Price |
$27.60
|
| Rate for Payer: Cigna Commercial |
$84.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$51.48
|
| Rate for Payer: Health EOS Commercial |
$81.88
|
| Rate for Payer: HFN Commercial |
$84.64
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.00
|
| Rate for Payer: Multiplan Commercial |
$73.60
|
| Rate for Payer: NAPHCARE Commercial |
$55.20
|
| Rate for Payer: Preferred Network Access Commercial |
$84.64
|
| Rate for Payer: Quartz Beloit One Network |
$45.08
|
| Rate for Payer: Quartz Commercial |
$59.80
|
| Rate for Payer: Quartz Medicare Advantage |
$55.20
|
| Rate for Payer: The Alliance Commercial |
$368.00
|
| Rate for Payer: WEA Trust Commercial |
$50.60
|
| Rate for Payer: WPS Commercial |
$68.14
|
|
|
DRESSING BIOPATCH 1X7MM HOLE 4152
|
Facility
|
IP
|
$175.00
|
|
| Hospital Charge Code |
2963970
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.75 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$105.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
DRESSING BIOPATCH 1X7MM HOLE 4152
|
Facility
|
OP
|
$175.00
|
|
| Hospital Charge Code |
2963970
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$157.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$150.50
|
| Rate for Payer: Aetna Managed Medicare |
$49.00
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$113.75
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$87.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$84.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$92.75
|
| Rate for Payer: Cash Price |
$52.50
|
| Rate for Payer: Cigna Commercial |
$161.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$97.93
|
| Rate for Payer: Health EOS Commercial |
$155.75
|
| Rate for Payer: HFN Commercial |
$161.00
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.25
|
| Rate for Payer: Multiplan Commercial |
$140.00
|
| Rate for Payer: NAPHCARE Commercial |
$105.00
|
| Rate for Payer: Preferred Network Access Commercial |
$161.00
|
| Rate for Payer: Quartz Beloit One Network |
$85.75
|
| Rate for Payer: Quartz Commercial |
$113.75
|
| Rate for Payer: Quartz Medicare Advantage |
$105.00
|
| Rate for Payer: The Alliance Commercial |
$700.00
|
| Rate for Payer: WEA Trust Commercial |
$96.25
|
| Rate for Payer: WPS Commercial |
$129.62
|
|
|
DRESSING BRIDGE XG #M827504415
|
Facility
|
IP
|
$1,549.00
|
|
| Hospital Charge Code |
2974092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$759.01 |
| Max. Negotiated Rate |
$1,425.08 |
| Rate for Payer: Aetna Commercial |
$1,394.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,332.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$820.97
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cigna Commercial |
$1,425.08
|
| Rate for Payer: Health EOS Commercial |
$1,378.61
|
| Rate for Payer: HFN Commercial |
$1,425.08
|
| Rate for Payer: Multiplan Commercial |
$1,239.20
|
| Rate for Payer: NAPHCARE Commercial |
$929.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,425.08
|
| Rate for Payer: Quartz Beloit One Network |
$759.01
|
| Rate for Payer: Quartz Commercial |
$929.40
|
| Rate for Payer: WEA Trust Commercial |
$851.95
|
| Rate for Payer: WPS Commercial |
$1,147.34
|
|
|
DRESSING BRIDGE XG #M827504415
|
Facility
|
OP
|
$1,549.00
|
|
| Hospital Charge Code |
2974092
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$433.72 |
| Max. Negotiated Rate |
$6,196.00 |
| Rate for Payer: Aetna Commercial |
$1,394.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,332.14
|
| Rate for Payer: Aetna Managed Medicare |
$433.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,006.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$774.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$743.52
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$820.97
|
| Rate for Payer: Cash Price |
$464.70
|
| Rate for Payer: Cigna Commercial |
$1,425.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$866.82
|
| Rate for Payer: Health EOS Commercial |
$1,378.61
|
| Rate for Payer: HFN Commercial |
$1,425.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,161.75
|
| Rate for Payer: Multiplan Commercial |
$1,239.20
|
| Rate for Payer: NAPHCARE Commercial |
$929.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,425.08
|
| Rate for Payer: Quartz Beloit One Network |
$759.01
|
| Rate for Payer: Quartz Commercial |
$1,006.85
|
| Rate for Payer: Quartz Medicare Advantage |
$929.40
|
| Rate for Payer: The Alliance Commercial |
$6,196.00
|
| Rate for Payer: WEA Trust Commercial |
$851.95
|
| Rate for Payer: WPS Commercial |
$1,147.34
|
|
|
DRESSING CALCIUM ALGINATE 4X4 MSC7344EPZ
|
Facility
|
OP
|
$87.00
|
|
| Hospital Charge Code |
5553372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.36 |
| Max. Negotiated Rate |
$348.00 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Aetna Managed Medicare |
$24.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$56.55
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$43.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$41.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$48.69
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$65.25
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$56.55
|
| Rate for Payer: Quartz Medicare Advantage |
$52.20
|
| Rate for Payer: The Alliance Commercial |
$348.00
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
DRESSING CALCIUM ALGINATE 4X4 MSC7344EPZ
|
Facility
|
IP
|
$87.00
|
|
| Hospital Charge Code |
5553372
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$80.04 |
| Rate for Payer: Aetna Commercial |
$78.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$74.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$46.11
|
| Rate for Payer: Cash Price |
$26.10
|
| Rate for Payer: Cigna Commercial |
$80.04
|
| Rate for Payer: Health EOS Commercial |
$77.43
|
| Rate for Payer: HFN Commercial |
$80.04
|
| Rate for Payer: Multiplan Commercial |
$69.60
|
| Rate for Payer: NAPHCARE Commercial |
$52.20
|
| Rate for Payer: Preferred Network Access Commercial |
$80.04
|
| Rate for Payer: Quartz Beloit One Network |
$42.63
|
| Rate for Payer: Quartz Commercial |
$52.20
|
| Rate for Payer: WEA Trust Commercial |
$47.85
|
| Rate for Payer: WPS Commercial |
$64.44
|
|
|
DRESSING CHANGE, SURGICAL
|
Facility
|
OP
|
$291.00
|
|
| Hospital Charge Code |
2959998
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$81.48 |
| Max. Negotiated Rate |
$1,164.00 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Aetna Managed Medicare |
$81.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$189.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$145.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$139.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$162.84
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$218.25
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$189.15
|
| Rate for Payer: Quartz Medicare Advantage |
$174.60
|
| Rate for Payer: The Alliance Commercial |
$1,164.00
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
DRESSING CHANGE, SURGICAL
|
Facility
|
IP
|
$291.00
|
|
| Hospital Charge Code |
2959998
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$142.59 |
| Max. Negotiated Rate |
$267.72 |
| Rate for Payer: Aetna Commercial |
$261.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$250.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$154.23
|
| Rate for Payer: Cash Price |
$87.30
|
| Rate for Payer: Cigna Commercial |
$267.72
|
| Rate for Payer: Health EOS Commercial |
$258.99
|
| Rate for Payer: HFN Commercial |
$267.72
|
| Rate for Payer: Multiplan Commercial |
$232.80
|
| Rate for Payer: NAPHCARE Commercial |
$174.60
|
| Rate for Payer: Preferred Network Access Commercial |
$267.72
|
| Rate for Payer: Quartz Beloit One Network |
$142.59
|
| Rate for Payer: Quartz Commercial |
$174.60
|
| Rate for Payer: WEA Trust Commercial |
$160.05
|
| Rate for Payer: WPS Commercial |
$215.54
|
|
|
DRESSING COBAN 6 X 5 YRD LF UNSTERILE 2086
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS A6455
|
| Hospital Charge Code |
2963675
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.44 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna Commercial |
$65.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$62.78
|
| Rate for Payer: Aetna Managed Medicare |
$20.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$47.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$36.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.69
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cigna Commercial |
$67.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.85
|
| Rate for Payer: Health EOS Commercial |
$64.97
|
| Rate for Payer: HFN Commercial |
$67.16
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.75
|
| Rate for Payer: Multiplan Commercial |
$58.40
|
| Rate for Payer: NAPHCARE Commercial |
$43.80
|
| Rate for Payer: Preferred Network Access Commercial |
$67.16
|
| Rate for Payer: Quartz Beloit One Network |
$35.77
|
| Rate for Payer: Quartz Commercial |
$47.45
|
| Rate for Payer: Quartz Medicare Advantage |
$43.80
|
| Rate for Payer: The Alliance Commercial |
$292.00
|
| Rate for Payer: WEA Trust Commercial |
$40.15
|
| Rate for Payer: WPS Commercial |
$54.07
|
|
